Risks of Electronic Cigarettes Include Unintentional Ingestion of Liquid Nicotine
BY JEFF BAUER
A recent case report of a 6-year-old girl who developed severe toxicity and required intubation after an unintentional exposure to liquid nicotine emphasizes a potential danger of commercially available liquid nicotine, which is highly concentrated, unreliably packaged, and poorly regulated.
Liquid nicotine is commonly sold in concentrated “refill” solutions intended for electronic cigarette users to dilute themselves. Previous studies have found that these refill products have unreliable commercial labeling, and that the actual nicotine concentration of these solutions can vary widely from the advertised concentration.
In this case report, the girl’s mother had purchased a concentrated nicotine solution online and had used an empty ibuprofen bottle, which she relabeled as “NIC,” to dilute the solution. Afterward, the patient’s father gave his daughter a 10-mL dose of the liquid from the repurposed bottle, believing it to be ibuprofen. Immediately upon consumption, the girl experienced a burning sensation in her mouth and throat. When the father tasted the liquid, he realized it contained the nicotine solution.
Within 5 minutes of the ingestion, the patient’s father called the regional poison control center and emergency medical services, while the girl’s mother attempted to manually induce vomiting, which produced only a small amount of emesis. When the paramedics arrived, the girl was conscious and breathing spontaneously, but she did not respond to questions or follow commands. The only intervention the paramedics performed was insertion of a peripheral intravenous line.
The girl arrived at the ED approximately 25 minutes after having ingested the nicotine. Her vital signs were: temperature, 95.4°F; heart rate (HR), 140 to 150 beats/min; and blood pressure, 93/70 mm Hg. Oxygen saturation was 95% on room air. She was alternately agitated and unresponsive. Her HR decreased to 60 beats/min, and she developed vomiting, diaphoresis, fasciculations, obtundation, and copious secretions. She was given ondansetron (0.1 mg/kg) and lorazepam (0.05 mg/kg), and within 6 minutes from arrival, she was sedated and intubated. Activated charcoal (25 g) was administered via nasogastric tube, and she was admitted to the pediatric intensive care unit.
Laboratory results from blood drawn upon the girl’s arrival at the ED indicated elevated lactate, creatinine, and potassium levels. A serum sample obtained 60 minutes after the girl had ingested the liquid was notable for elevated levels of nicotine (348 ng/mL). With the parents’ permission, the liquid in the ibuprofen container was analyzed and found to contain nicotine, 70.3 mg/mL, which meant the girl had consumed 703 mg of nicotine, or 35 mg/kg. A recent review suggested a fatal nicotine dose of 500 to 1,000 mg in adults. Assuming the mother had correctly diluted the liquid nicotine by half as she had intended to, the original product’s nicotine concentration was 140.6 mg/mL, or 234% of the amount listed on the package (60 mg/mL).
The girl remained sedated and intubated overnight without requiring additional medication or treatment. She was extubated the next morning. Her lactate, creatinine, and potassium levels returned to normal, and electrocardiography and chest radiography results were normal. She was discharged home in stable condition. The Department of Human Services conducted a brief investigation, which they closed when the patient was discharged.
The authors of this case report concluded that emergency physicians (EPs) should be aware of the widespread availability of liquid nicotine products, and the potential of severe toxicity from ingestion of liquid nicotine.
Noble MJ, Longstreet B, Hendrickson RG, Gerona R. Unintentional pediatric ingestion of electronic cigarette nicotine refill liquid necessitating intubation. Ann Emerg Med. 2017;69(1):94-97. doi:10.1016/j.annemergmed.2016.08.448.
Emergency Radiologists’ Job Satisfaction Tied to How Often They Have to Work Overnight Shifts
BY JEFF BAUER
According to a recent survey of emergency radiologists, those who frequently work overnight shifts are less likely to be satisfied with their job than counterparts who work fewer or no overnight shifts.
Approximately 1,100 emergency radiologists received an e-mail invitation to complete an online survey; 327 did so (29.6% response rate). Seventy-three percent of respondents were male, 69% were age 40 years or older, and 87% practiced full-time. Respondents were asked to rate statements such as “I enjoy my job” and “At times I feel overwhelmed at work” on a Likert scale from “disagree or strongly disagree” to “agree or strongly agree.”
Overall, 81% of respondents reported some measure of job enjoyment. There was an association between the average number of overnight shifts performed per year and job enjoyment. Emergency radiologists who did no overnight shifts were 2.21 times more likely to report enjoying their job than those who worked 17 weeks or more of overnight shifts a year.